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Clinical decision support system. A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow.
Canada has established a research chair that focusses on practical methods for promoting and implementing shared decision-making across the healthcare continuum. [65] Shared decision-making in medicine (SDM) is a process in which both the patient and physician contribute to the medical decision-making process and agree on treatment decisions. [1]
The SOAP note(an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. [1][2]Documenting patient encounters in the medical recordis an integral part of practice workflow starting ...
t. e. Clinical psychology is an integration of human science, behavioral science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. [ 1 ][ 2 ] Central to its practice are psychological assessment ...
The therapeutic relationship refers to the relationship between a healthcare professional and a client or patient. It is the means by which a therapist and a client hope to engage with each other and effect beneficial change in the client. In psychoanalysis the therapeutic relationship has been theorized to consist of three parts: the working ...
Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or